Healthcare Provider Details

I. General information

NPI: 1790908622
Provider Name (Legal Business Name): EAST GEORGIA PREVENTATIVE HEALTH SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S LEROY ST STE A
METTER GA
30439-4631
US

IV. Provider business mailing address

150 S LEROY ST STE A
METTER GA
30439-4631
US

V. Phone/Fax

Practice location:
  • Phone: 912-685-7498
  • Fax: 912-685-3777
Mailing address:
  • Phone: 912-685-7498
  • Fax: 912-685-3777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License NumberPHRE008829
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. BOBBY DEAN STONE JR.
Title or Position: OWNER
Credential: RPH, CDM
Phone: 912-685-7498